Low-Dose Dexamethasone Following IVIG in Pediatric Inflammatory Multisystem Syndrome in Temporal Association with COVID-
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SCIENTIFIC LETTER
Low-Dose Dexamethasone Following IVIG in Pediatric Inflammatory Multisystem Syndrome in Temporal Association with COVID-19 (PIMS-TC) Priyanka Meena 1 & Pallavi 1 & Devendra Mishra 1 & Urmila Jhamb 1 & Meenakshi Aggarwal 2 Received: 8 August 2020 / Accepted: 17 September 2020 # Dr. K C Chaudhuri Foundation 2020
To the Editor: Pediatric inflammatory multisystem syndrome – temporally associated with SARS-CoV-2 (PIMS-TS) is a severe form of illness caused by Severe acute respiratory syndrome coronavirus–2 (SARS-CoV-2), characterised by hyperinflammatory response and multiorgan dysfunction [1]. Immunotherapy forms the basis of management. We report a child with PIMS-TS managed with IVIG and low-dose dexamethasone. A 10-y-old male presented with fever, myalgia, headache, cough, throat pain, redness of eyes, rash, pain abdomen, vomiting and respiratory distress, three weeks after contact with COVID-19 positive relatives. He had tachycardia, tachypnea with retractions, SpO2 of 89%, conjunctivitis, cheilitis, rash, edema, hepatomegaly and meningismus. Investigations revealed anemia, leucocytosis with neutrophilia and lymphopenia, normal platelets, deranged kidney and liver functions, hypoalbuminemia, positive C-reactive protein (CRP) and elevated lactate dehydrogenase (443 U/L), total creatine phosphokinase (> 1600 IU/L), pro-B-type-natriuretic peptide (24,838 pg/ml), interleukin-6 (685.5 pg/ml), procalcitonin (65.0 ng/ml), D-dimer (2573 ng/ml), ferritin (808.4 ng/ml) and triglycerides (357 mg/dl). He had acute respiratory distress syndrome (ARDS) with features of classic COVID on chest X-ray. Rapid antigen test and RT-PCR for SARS-CoV-2 were negative. Anti-SARS-CoV-2 immunoglobulin G (IgG) was positive, with IgG optical density value 1.7 (Cut off—0.65) and IgG index 2.4 (Erbalisa Covid -19 IgG ELISA kit). Patient was started on high flow nasal
* Pallavi [email protected] 1
Department of Pediatrics, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi 110002, India
2
Department of Microbiology, Kalawati Saran Children’s Hospital & Lady Hardinge Medical Hospital, New Delhi, India
cannula, antibiotics and inotropes. After giving IVIG at 2 g/kg, fever and need for respiratory and circulatory support persisted with CRP > 150 mg/L. Hence, intravenous dexamethasone was started (0.2 mg/kg/d OD). He improved with normalisation of inflammatory markers (CRP– 6 mg/L, interleukin-6 < 1.5 pg/ml) and was discharged on tapering dose of oral dexamethasone. PIMS-TS occurs 2–4 wk after SARS-CoV-2 infection and shares features with Kawasaki disease (KD). Clinical features and hyperinflammatory state reported are similar to that of our patient [1]. The exact mechanism is unknown; an aberrant cellular or humoral immune response leading to overt inflammation with multiorgan dysfunction is postulated [1]. IVIG has been used as the first-line therapy, which acts by binding of its Fc fragment with Fc-gamma receptors on inflammatory cells [2]. Some patients fail to respond to IVIG; the risk facto
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